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<!DOCTYPE html>
<html>
<head>
<link href="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.6/css/bootstrap.min.css" rel="stylesheet" type="text/css" />
<script src="https://code.jquery.com/jquery.min.js"></script>
  <meta charset="utf-8">
  <title>JS Bin</title>
</head>
<body>
  
<div class="container">
  <div class="row-fluid">
    
    <form>
      
      
      <!--/are you interested in social security or veterans disability benefits  STEP ONE -->
      <div class="row stepOne">
        <p><strong>Are you interested in social security or veterans' disability benefits?</strong></p>
        <div class="col-sm-4">
          <div class="radio">
            <label><input type="radio" name="interested" id="interested-one" value="veterans">Veterans'</label>
          </div>
        </div>
        <div class="col-sm-4">
          <div class="radio">
            <label><input type="radio" name="interested" id="interested-two" value="social-security">Social Security</label>
           </div>
        </div>
        <div class="col-sm-4">
          <div class="radio">
            <label><input type="radio" name="interested" id="interested-three" value="both">Both</label>
           </div>
        </div>
      </div><!--/row-->
      
      
      
      
      <!-- are you a current client? STEP TWO -->
      <div class="row stepTwo">
        <p><strong>Are you a current client?</strong></p>
        <div class="col-sm-6">
          <div class="radio">
            <label><input type="radio" name="current" id="current-one" value="current-yes">Yes</label>
          </div>
        </div>
        <div class="col-sm-6">
          <div class="radio">
            <label><input type="radio" name="current" id="current-two" value="current-no">No</label>
           </div>
        </div>
      </div><!--/row-->
      
      
      
      <!-- are you receiving social security disability? STEP THREE -->
      <div class="row stepThree">
        <p><strong>Are you currently receiving social security disability?</strong></p>
        <div class="col-sm-6">
          <div class="radio">
            <label><input type="radio" name="currentlyReceiving" id="currentlyReceiving-one" value="currentlyReceiving-yes" checked>Yes</label>
          </div>
        </div>
        <div class="col-sm-6">
          <div class="radio">
            <label><input type="radio" name="currentlyReceiving" id="currentlyReceiving-two" value="currently-receiving-no" checked>No</label>
           </div>
        </div>
      </div><!--/row-->
      
      
      
      <!-- are you working more than 10 hours per week? STEP Four-->
      <div class="row stepFour">
        <p><strong>Are you currently working more than 10 hours per week?</strong></p>
        <div class="col-sm-6">
          <div class="radio">
            <label><input type="radio" name="currentlyWorking" id="currentlyWorking-one" value="currentlyWorking-yes" checked>Yes</label>
          </div>
        </div>
        <div class="col-sm-6">
          <div class="radio">
            <label><input type="radio" name="currentlyWorking" id="currentlyWorking-two" value="currentlyWorking-no" checked>No</label>
           </div>
        </div>
      </div><!--/row-->
      
      
      
      
      
      <!-- are you unable to work a full time job because of your disability? STEP FIVE-->
      <div class="row stepFive">
        <p><strong>Are you currently unable to work a full time job because of your disability?</strong></p>
        <div class="col-sm-6">
          <div class="radio">
            <label><input type="radio" name="unable" id="unableOne" value="unable-yes">Yes</label>
          </div>
        </div>
        <div class="col-sm-6">
          <div class="radio">
            <label><input type="radio" name="unable" id="unableTwo" value="unable-no">No</label>
           </div>
        </div>
        <button type="submit" class="btn btn-primary">Submit</button>
      </div><!--/row-->
      
      
      
      
      
      
      <!-- customer information -->
      <section id="customer-information">
      <div class="form-group">
        <label for="fname" class="sr-only">First Name</label>
        <input type="text" class="form-control" id="fname" placeholder="First Name">
      </div>
      
      <div class="form-group">
        <label for="lname" class="sr-only">Last Name</label>
        <input type="text" class="form-control" id="lname" placeholder="Last Name">
      </div>
      
      <div class="form-group">
        <label for="phone" class="sr-only">Phone Number</label>
        <input type="phone" class="form-control" id="phone" placeholder="Phone Number">
      </div>
      
      <div class="form-group">
        <label for="email" class="sr-only">Email</label>
        <input type="email" class="form-control" id="email" placeholder="Email Address">
      </div>
      
      <div class="form-group">
        <label for="email" class="sr-only">Email</label>
        <textarea class="form-control" id="message" placeholder="Your Message"></textarea>
      </div>
        <button type="submit" class="btn btn-primary">Submit</button>
      </section><!--/customer information -->
      
      
      
    </form>
    
  </div>
</div>
  
  
  
  
  
  <script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.6/js/bootstrap.min.js"></script>
</body>
</html>
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